Karen deKay, MSN, RN, CNOR, CICPerioperative Practice SpecialistAORN

Deva Rea, MPH, BSN, RN, CICClinical Science LiaisonPDI

Objectives

Recognize the impact of decolonization on reducing skin flora and surgical site infections

Navigate risk-based decisions for developing preoperative decolonization programs using the updated AORN guideline for preoperative patient skin antisepsis

Patient Story – Rosie Bartel

Advocate 3.3 Billion Dollars

1 Million Inpatient

Days

3% Mortality

Rate

75% Attributable

to SSI

Colonization

(https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf)

DefinitionsColonization: Asymptomatic carriage of organisms (such as S aureus) on skin, in body fluids, or tissues that are not causing a clinically adverse effect for the individual

Decolonization: Practice of treating patients with known S aureus colonization with antimicrobial and/or antiseptic agents to suppress or eradicate S aureus colonization

Methicillin-susceptible S aureus (MSSA): strain of S aureus that does respond to methicillin but remains resistant to other beta-lactam antibiotics and cephalosporins

Methicillin-resistant S aureus (MRSA): strain of S aureus that is resistant to all types of beta-lactam antibiotics, as well as cephalosporins

Colonization can lead to infection….

https://www.cdc.gov/infectioncontrol/training/strive.html#anchor_MRSA

S aureus Colonization Sites

Most often colonizes nares

30% with both skin and intranasal colonization

75% with nasal carriage are colonized

at 1 or more extra-nasal sites

(Mermel LA et al. J Clin Microbiol 2011; 49:1119)

a. 1b. 3c. 5d. 10

How many times per day does the average person touch their nose?

Polling Question #1

How many times per day does the average person touch their nose?

a. 1b. 3c. 5d. 10

(Kwok et al.,2015)

a. 20%b. 30%c. 50%d. 80%

What is the percentage of S aureus SSIs that can be attributed to the patient’s own bacteria?

Polling Question #2

S aureus and SSIs

Endogenous Leading pathogen

2- to 9-fold increase

80% to patient’s own bacteria

(Pal et al., 2019; Sakr et al, 2018)

(Weiner-Lastinger et al., ICHE 2020)

Causative SSI Pathogens per CDC NHSN(2015-2017)

a. Methicillin-resistant Staphylococcus aureus (MRSA)b. Methicillin-susceptible Staphylococcus aureus (MSSA)c. MRSA and MSSAd. Vancomycin-resistant Enterococci (VRE)

Which specific organism(s) should be targeted for surgical patient decolonization?

Polling Question #3

a. Methicillin-resistant Staphylococcus aureus(MRSA)

b. Methicillin-susceptible Staphylococcus aureus (MSSA)

c. MRSA and MSSAd. Vancomycin-resistant Enterococci (VRE)

Which specific organisms should be targeted for surgical patient decolonization?

MRSA and MSSA

MRSA ~1-3%

MSSA ~30%

Screening for both is necessary• Mediastinitis study

• Cardiothoracic and orthopedic study

(San Juan R., et al, 2007; Septimus & Schweizer, 2016; Van Rijen M.M.L., et al, 2013)

AORN Guideline for Preoperative Patient Skin Antisepsis

E-release: May 2021

Book Publication: 2022

Team Decision• Suggested Members• Risk-based• Resources• Proceed (yes/no)

Interdisciplinary TeamInfection

Preventionists

Epidemiologists

Pharmacists

Perioperative RNs Surgeons

Microbiology lab

personnel

Other stakeholders

Local Epidemiology & Procedures

Prevalence in

CommunityS aureus SSIs

Antibiotic Susceptibility

Profile

High Risk Procedures

• CABG and Valve Replacement

• Cardiac Assist Devices• Total Joint Replacement• Spinal Fusion• Trauma Patients with

Device Implantation

https://www.cdc.gov/mrsa/community/photos/photo-mrsa-9.html

https://text.apic.org/toc/microbiology-and-risk-factors-for-transmission/antimicrobials-and-resistance

https://www.cdc.gov/mrsa/community/photos/photo-mrsa-1.html

a. Asthmab. Cerebral vascular accident (CVA)c. Middle aged. Obesity

Which of the following is NOT a patient risk factor for colonization with S aureus?

Polling Question #4

Some Patient Risk Factors (Table 1)

Indwelling medical device

Living in congregant

setting

Advance age

(adults over age

65)

History of CVA Obesity

(BMI >30)• Asthma• End stage liver

disease• Cardiac• Diabetes• Immuno-

compromised

Underlying diseases such as:

(Campbell KA et al., 2015; Herwaldt et al., 2004; Siegal et al, 2006)

Develop Program• Strategy• Protocol• Timing

1.2,1.3,1.3.1,1.3.2, 1.4.1

Decolonization Strategies

Universal• General

population

Targeted• Select

population

Blended• Combines

strategies

(Septimus & Schweizer, 2016)

Characteristic Universal Targeted

Implementation Easier as everyone receives Challenging for screening, reporting of results, receiving product

Sensitivity 100% (Staphylococcus aureus carriers will not be missed)

Some patients may not be screened, the test procedure may not have 100% sensitivity, and non-nasal S aureus carriers may be missed

Product volume Approximately 5 times that in the targeted strategy

For detected S aureus carriers only

Screening No screening All patients

Cost Allocation of product Screening, reporting, allocation of product

(Septimus & Schweizer, 2016)

Decolonization Protocols • Mupirocin• Intranasal• Intranasal + Skin Agent

Antibiotic (Table 3)

• Povidone-iodine; Alcohol-based• Intranasal• Intranasal + Skin Agent

Antiseptic (Table 4)

Table 5: Health Agency & Professional Society RecommendationsEntity Nasal Protocol Skin Protocol

American College of Surgeons and Surgical Infection Society, 2016

Nasal mupirocin 2% No recommendation

American Hospital Association, 2013 Nasal mupirocin or nasal povidone iodine at least 3 days prior to surgery

Chlorhexidine gluconate (CHG)

American Society of Health-System Pharmacists, 2013

Nasal mupirocin 2% No recommendation

Centers for Disease Control and Prevention, 2019

Intranasal anti-staphylococcal antibiotic/antiseptic (eg, mupirocin or iodophor)

CHG

National Association of Orthopaedic Nurses, 2013

Nasal mupirocin 2% bid until time of procedure

No recommendation

National Institute for Health and Care Excellence, 2019

Nasal mupirocin 2% CHG

Society for Healthcare Epidemiology of America/Infectious Diseases Society of America, 2014

Anti-staphylococcal agent No recommendation

World Health Organization, 2016 Nasal mupirocin 2% with or without skin decolonization

If used, CHG

Timing Ideally before procedure• Screen/results• Product obtainment• ? Continue postoperatively

Urgent/emergent procedures

(Saraswat et al., 2017; Kohler et al., 2015)

Implement

Procure• Reliable• Easy• Continuous

Educate • Patient &

HCW• Procedure• Benefit

Monitor• Adherence • CHG• Mupirocin

1.4.2, 1.4.3, 1.4.4, 1.5,1.5.1

Weigh Factors

Epidemiology

Surgical Population

Weigh FactorsNumber of

applications

Patient compliance

Persistence

Cost

Screening for resistance

# of robust studies

# studies in your surgical population

Epidemiology

Surgical Population

Thank you!

References• Campbell KA, Cunningham C, Hasan S, Hutzler L, Bosco JA,3rd. Risk factors for developing staphylococcus aureus nasal

colonization in spine and arthroplasty surgery. Bull Hosp Jt Dis (2013). 2015;73(4):276-281 • Centers for Disease Control. National Healthcare Safety Network (NHSN). Surgical site infection event. In Procedure-

associated Module. January 2021: CDC 9-1 – 9-2.• Herwaldt L, Cullen J, French P, et al. Preoperative risk factors for nasal carriage of staphylococcus aureus. Infect Control

Hosp Epidemiol. 2004;25(6):481-484.• Kohler P, Sommerstein R, Schonrath F, et al. Effect of perioperative mupirocin and antiseptic body wash on infection rate

and causative pathogens in patients undergoing cardiac surgery. Am J Infect Control. 2015;43(7):e33-8• Kwok YO, Gralton J, McLaws, ML. Face touching: A frequent habit that has implications for hand hygiene.

AJIC.2015;43:112-114.• Mermel, L. A., Cartony, J. M., Covington, P., Maxey, G., & Morse, D. (2011). Methicillin-resistant Staphylococcus aureus

colonization at different body sites: a prospective, quantitative analysis. Journal of clinical microbiology, 49(3), 1119–1121. • Olmsted, R. Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia.

https://www.cdc.gov/infectioncontrol/training/strive.html#anchor_MRSA• Pal S, Sayana A, Joshi A, Juyal D. Staphylococcus aureus: A predominant cause of surgical site infections in a rural

healthcare setup of Uttarakhand. J Family Med Prim Care. 2019;8(11):3600-3606.

References cont…• Sakr A, Brégeon F, Mège JL, Rolain JM, Blin O. Staphylococcus aureus Nasal Colonization: An Update on Mechanisms,

Epidemiology, Risk Factors, and Subsequent Infections. Front Microbiol. 2018;9:2419.• San Juan, R., Chaves, F., Gude M.J.L., et al. Staphylococcus aureus poststernotomy mediastinitis: Description of two

distinct acquisition pathways with different potential preventative approaches. J Thorac Cardiovasc Surg 2007;134:670-676.• Saraswat, M. K., Magruder, J. T., Crawford, T. C., et al. Preoperative Staphylococcus aureus screening and targeted

decolonization in cardiac surgery. Ann Thorac Surg. 2017;104:1349-1356• Septimus EJ, Schweizer ML. 2016. Decolonization in prevention of health care-associated infections. Clin Microbiol Rev

29:201–222.• Siegal, JD, Rhinehart E, Jackson, M & Chiarello, L. Management of Multidrug-resistant organisms in healthcare settings,

2006. Last updated February 15, 2017. https://www.cdc.gov/infectioncontrol/guidelines/mdro/• Van Rijen M.M.L., Bode,L.G., Baak D.A., et al. Reduced costs for Staphylococcus aureus carriers treated prophylactically

with mupirocin and chlorhexidine in cardiothoracic and orthopedic surgery. PLOS one 2013;7:e42065• Weiner-Lastinger LM, Abner S, Edwards JR, et al. Antimicrobial-resistant pathogens associated with adult healthcare-

associated infections: Summary of data reported to the National Healthcare Safety Network, 2015-2017. Infect Control Hosp Epidemiol. 2020 Jan;41(1):1-18.

Using Profend® Nasal Decolonization Kit Putting Guidelines into Practice

Deva Rea MPH, BSN, RN, CICMarc-Oliver Wright MT(ASCP), MS, CIC, FAPIC

Objectives• Identify how Profend® Nasal Decolonization Kit fits into the

new guidelines• Define elements for successful product implementation• Highlight customer success story using Profend® Nasal

Decolonization Kit

First Polling QuestionAre you currently decolonizing the nose pre-operatively?1. Yes, for all procedures2. Yes, but only for high-risk procedures3. No, not performing nasal decolonization4. I don’t know

Second Polling QuestionWhat type of nasal decolonization practice is being deployed at your facility?1. Targeted decolonization2. Universal decolonization3. Blended – depends on the situation (procedure, MD, etc.)4. None5. I don’t know

Decolonization Strategies• Profend® swabsticks work for all decolonization strategies:

• Universal: • Broad spectrum activity against S. aureus, MRSA, and other bacteria1

• May remove the need to screen pre-operatively for MSSA• No evidence of bacterial resistance• Can be used in emergent procedures

• Targeted: • Reduces 99.7% of S. aureus at 10 minutes, 1 hour and 99.9%

at 12 hours for patients testing (+) for MSSA/MRSA2

1. PDI in vitro Study PDI-0113-KT12. PDI in vivo Study PDI-0113-CTEV01

Procurement• Profend® Nasal Decolonization Kit

is readily available through your medical supply distributor

• Product packaging:• 4 swabs in 1 patient kit• 12 patient kits in 1 box (shelf unit) • 4 shelf units/case

Timing and Protocol• No additional resources needed• Treatment via standing physician order or nurse driven protocol as

part of the SSI prevention bundle• No prescription required; no prescription cost to the patient

• Application is simple and efficient and easily fits within the pre-operative workflow

• Application 1 hour pre-procedure; 10-minute pre-procedure for emergent cases

• In vivo data shows a 99.9% reduction of S. aureus at 12 hours3 post application providing coverage during the highest risk period

3. PDI in vivo Study PDI-0113-CTEV01

Implementation and Application• Quick, 60 second total treatment time – Up to 2.5x faster

application than other PVP-Iodine swabs4

• 4 swabsticks/patient (2 each nostril); 15 sec. for each application• Neat, dry-handle design minimizes mess

• Pre-saturated swabs need no preparation – just snap and swab• Slim, compact design for patient comfort

• Assured treatment compliance as product is applied by clinician 1 hour prior to surgery

• 96.6% of patients surveyed are comfortable with nasal application of PVP-Iodine5

4. Instructions for use5. Maslow J, Hutzler L, Cuff G, Rosenberg A, Phillips M, Bosco J. Patient experience with mupirocin or povidone-iodine nasal decolonization. Orthopedics. 2014;37(6):e576–e581.

Education• Education is provided to the

healthcare workers via onsite/virtual vendor training, online training module, video and written Profend® IFU

• Patient brochures are also available including QR code for video IFU

Third Polling QuestionWhat is the total treatment time for Profend® swabsticks application?1. 120 secs (2 minutes): 30 sec. each for 4 swabsticks2. 60 secs (1 minute): 15 sec. each for 4 swabsticks3. 60 secs (1 minute): 30 sec. each for 2 swabsticks4. I don’t remember!

Elements of Successful Implementation• Product readily available• Nurses/healthcare workers trained on new product• Patients informed and accepting of protocol• Process fits nicely into workflow• Process easy to monitor for compliance• Positive patient outcomes

Nasal PVP-I implementation for preventing surgical site infections: Perspectives of surgical nursesPurpose: “To evaluate the implementation feasibility, fidelity and acceptability of intranasal PI (Povidone-Iodine) solution application by surgical nurses using the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) conceptual framework.”6

6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217

Nasal PVP-I implementation for preventing surgical site infections: Perspectives of surgical nursesMethod: Qualitative study6

• 2 facilities used different methods for implementation of PVP-I pre-surgical

• ASC (facility A) and Acute Care OR (facility B)• Used conceptual framework to develop interview questions

and analyzed the data using deductive content analysis• Evaluated nurses’ experience/perceptions on preoperative

intranasal decolonization product implementation6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217

Results – Takeaways • Role of an implementation facilitator is critical to the success of

product adoption• Ensure facility notifies staff of new product implementation and

include why• Ensure sufficient information given pre-implementation stage to

nurses to develop competence in explaining to patients • Video training worked well (facility B) to convey product use, and

allowed for a resource to reference• Protocol should be formal and written for indefinite reference• Use a variety of educational tools

6. Hammond EN, Brys N, Kates A, Musuuza JS, Haleem A, Bentz ML, et al. (2020) Nasal povidone-iodine implementation for preventing surgical site infections: Perspectives of surgical nurses. PLoS ONE 15(11): e0242217. https://doi.org/10.1371/journal.pone.0242217

What Is the Impact of Prophylactic Nasal Decolonization in Prevention of SSI? Wagner et.al., Duke RaleighAbstracts / American Journal of Infection Control 48 (2020) S15−S58

Abstract:• Using principles of total quality management

(TQM) to implement a new broad spectrum antiseptic nasal swab product,

• An interdisciplinary team initiated nasal decolonization in elective total hip, total knee, and spinal fusion surgical patients.

Conclusions:• Found preoperative nasal povidone iodine

decolonization to be a safe, efficient, and cost-effective strategy in reducing SSIs in elective orthopedic surgeries. Patients and organizations may benefit from incorporating this strategy into preoperative SSI prevention protocols.

Results:• Zero SSIs for the 47 THAs and 79 TKA surgeries performed,

and only 1 SSI for the 320 SF surgeries completed • Collective SSI rate (0.002) decreased 60% from 3 months

prior and is 3 times lower than the SSI rate of the 797 other surgeries (0.006) performed during the 3-month nasal decolonization period

• No adverse safety events pertaining to nasal decolonization have been reported

• Due to the success of the nasal decolonization initiative, other surgeons outside of the pilot populations have requested the povidone iodine nasal swab administration for their patients preoperatively

Last Polling Question- it’s a tough oneWhat year was PVP-I first synthesized by the Toxicology Labs of Philadelphia?1. 19422. 19553. 19904. 2020

In summaryProfend® Nasal Decolonization Kit

Thank you!

Audience Q&A

53

Questions?

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